1. GRASP-AF The National Picture Vanessa Brown National Improvement Lead Ian Robson Senior Analyst

2. Outline AF and stroke Objective Management of stroke risk Changes to QOF GRASP-AF practical demonstration Q & A

3. Stroke is a frequent complication of AF Stroke is the leading complication of AF Patients with AF have a five-fold higher stroke risk than those without AF 1 AF doubles the risk of stroke when adjusted for other risk factors 2 Without preventive treatment, each year approximately 1 in 20 patients (5%) with AF will have a stroke 3 It is estimated that 15% of all strokes are caused by AF 5 and that 12,500 strokes per year in England are directly attributable to AF 6 1. NICE clinical guideline 36.June 2006. Available at http://www.nice.org.uk/guidance/CG36/?c=91497; accessed April 2010; 2. ACC/AHA/ESC guidelines: Fuster V et al. Circulation 2006;114:e257–354 & Eur Heart J 2006;27:1979–2030; 3. Atrial Fibrillation Investigators. Arch Intern Med 1994;154:1449–57; 4. Carlson M. Medscape Cardiology. 2004;8; available at http://cme.medscape.com; accessed Feb 2010; 5. Lip GYH, Lim HS. Lancet Neurol 2007;6:981-93; 6. NHS Improvement. June 2009. Available at http://www.improvement.nhs.uk/heart/Portals/0/documents2009/AF_Commissioning_Guide_v2.pdf; accessed April 2010http://www.nice.org.uk/guidance/CG36/?c=91497http://cme.medscape.comhttp://www.improvement.nhs.uk/heart/Portals/0/documents2009/AF_Commissioning_Guide_v2.pdf

4. Stroke is a serious complication of AF Stroke in AF is associated with a heavy burden of morbidity and mortality AF related stroke is usually more severe than stroke due to other causes 1 Compared with other stroke patients, those with AF are more likely to: –Have cortical deficit (e.g. aphasia), severe limb weakness and diminished alertness, and be bedridden on admission 2 –Have longer in-hospital stay with a lower rate of discharge to their own home 3 1. Savelieva I et al. Ann Med 2007;39:371–91; 2. Dulli DA et al. Neuroepidemiology 2003;22:118–23; 3. NICE clinical guideline 36.June 2006. Available at http://www.nice.org.uk/guidance/CG36/?c=91497; accessed April 2010;http://www.nice.org.uk/guidance/CG36/?c=91497 4. Benjamin EJ et al. Circulation 1998;98:946–52

5. Objective: To reduce the number of strokes caused by AF Improved detection and diagnosis –Raised awareness –Promote opportunistic detection Ensure optimal treatment for those diagnosed with AF –Improved assessment of risk- CHADS 2, CHA 2 DS 2 -VASc –Appropriate management of risk- GRASP-AF –Improve anticoagulation services

6. The GRASP-AF Tool to improve the management of AF Identifies patients on your system with diagnosed atrial fibrillation Searches for co-morbidities and works out both a CHADS 2 and CHA 2 DS 2 -VASc score Searches for current medication –warfarin, aspirin or newer oral anticoagulant Searches for recorded reasons for NOT treating with warfarin Gives a simple alert for those at high risk and not on warfarin or newer oral anticoagulant

7. QOF changes for 2012 / 13 Old target AF3 The percentage of patients with atrial fibrillation who are currently treated with anti-coagulant drug therapy or an anti-platelet drug therapy

8. QOF changes for 2012 / 13 New targets AF5 The percentage of patients with Atrial Fibrillation in whom stroke risk has been assessed using the CHADS 2 risk stratification scoring system in the preceding 15 months

9. QOF changes for 2012 / 13 New targets AF6 In those patients with Atrial Fibrillation in whom there is a record of a CHADS 2 score of 1, the percentage of patients who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy AF7 In those patients with Atrial Fibrillation in whom there is a record of a CHADS 2 score of greater than 1, the percentage of patients who are currently treated with anti-coagulation drug therapy

10. Ian Robson Senior Analyst, NHS Improvement Demonstration of GRASP-AF Live demonstration of CHART Online

11. The GRASP-AF tool What is it? Uses free / commonly used software A series of searches of a GPs clinical system Looks at patients with a history of AF Then looks at their medication and other relevant medical history Gives a practice over view – Dashboard Gives a patient list

12. The GRASP-AF tool

13. CHADS 2 / CHA 2 DS 2 -VASc Risk FactorCHADS 2 CHA 2 DS 2 -VASc Cardiac failure1 Congestive HF / LVSD 1 Hypertension11 Diabetes11 Stroke or TIA22 Age 65 - 74 1 Age >7512 Female 1

14. The GRASP-AF tool

17. QOF changes for 2012 / 13 New targets AF6 In those patients with Atrial Fibrillation in whom there is a record of a CHADS 2 score of 1, the percentage of patients who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy AF7 In those patients with Atrial Fibrillation in whom there is a record of a CHADS 2 score of greater than 1, the percentage of patients who are currently treated with anti-coagulation drug therapy

18. The GRASP-AF tool

20. What changes have been made? 626 practices uploaded more than once 2.32% increase in high risk patients on anticoagulation 68 AF-related strokes prevented 35 if population standardised 5.73% increase in high risk patients coded as anticoagulation contraindicated / declined

21. The GRASP-AF tool Future projections In all 1,746 practices that have uploaded data: 55.35% high risk patients on anticoagulation 35.90% high risk patients on antiplatelet 8.75% high risk patients on nothing 14.05% high risk patients coded as anticoagulation contraindicated / Declined Current treatment prevents 2,180 AF-related strokes / 1,482 deaths

22. The GRASP-AF tool Future projections If all 1,746 practices that have uploaded data: 85% high risk patients on anticoagulation 0% high risk patients on antiplatelet 15% high risk patients anticoagulation contraindicated / declined This treatment would prevent 2,743 AF-related strokes An increase of 564 Would prevent an extra 383 deaths

23. More Information Can be found at http://www.improvement.nhs.uk/graspaf/http://www.improvement.nhs.uk/graspaf/ E-mail support: Support for practices, networks and other organisations working with GRASP-AF Contact ian.robson@improvement.nhs.uk with your queryian.robson@improvement.nhs.uk Any Questions?